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The economic burden of time-loss injuries to youth players participating in week-long rugby union tournaments
Journal of Science and Medicine in Sport 18 (2015) 394–399
Contents lists available at ScienceDirect
Journal of Science and Medicine in Sport journal homepage: www.elsevier.com/locate/jsams
Original research
The economic burden of time-loss injuries to youth players participating in week-long rugby union tournaments James C. Brown b,a,∗ , Wayne Viljoen c , Mike I. Lambert a , Clint Readhead c , Chelsea Fuller a , Willem Van Mechelen b,a , Evert Verhagen b a UCT/MRC Research Unit for Exercise Science and Sports Medicine, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa b Department of Public and Occupational Health, EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands c South African Rugby Union (SARU), Cape Town, South Africa
a r t i c l e
i n f o
Article history: Received 6 December 2013 Received in revised form 27 June 2014 Accepted 29 June 2014 Available online 16 July 2014 Keywords: Football Football/economics Football/economics/cost analysis Football/injuries (MeSH terms)
a b s t r a c t Objectives: Rugby Union (“rugby”) is a popular sport with high injury risk. Burden of injury is described by the incidence and severity of injury. However reports have ignored the monetary cost of injuries. Therefore the aim of this study was to describe the monetary cost associated with youth rugby injuries. Design: This descriptive study quantified medical treatments of injured players at the South African Rugby Union Youth tournaments in 2011/2012 and the days of work parents missed as a result of the injuries. A health insurer used these data to calculate associated costs. Methods: Legal guardians of the 421 injured players were contacted telephonically on a weekly basis until they returned to play. Treatments costs were estimated in South African Rands based on 2013 insurance rates and converted to US$ using purchasing power parities. Results: Of the 3652 players, 2% (n = 71) sought medical care after the tournament. For these players, average treatment costs were high (US$731 per player, 95% CI: US$425–US$1096), with fractures being the most expensive type of injury. Players with medical insurance had higher costs (US$937, 95% CI: US$486–US$1500) than those without (US$220, 95% CI: US$145–US$302). Conclusions: Although a minority of players sought follow-up treatment after the tournaments, the cost of these injuries was high. Players without medical insurance having lower costs may indicate that these players did not receive adequate treatment for their injuries. Injury prevention efforts should consider injuries with high costs and the treatment of players without medical insurance. © 2014 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.
1. Introduction Participation in physical activity has numerous health benefits for children.1 However, physical activity can also pose the risk of health detriments, such as injury, the likelihood of which may vary depending on the mode of physical activity.2 This potential burden of injury may discourage participation in a particular sport, unless preventative measures are introduced effectively.2 Of all international sports, Rugby union (“rugby”) is arguably amongst the most popular, for all age groups, including youth.3 To better understand the injury problem, both the incidence and severity of a particular sport-related injury need to be accurately
∗ Corresponding author. E-mail addresses: [email protected], [email protected] (J.C. Brown).
quantified.2 The incidence of injury can be described by calculating the number of new injuries that occur taking into account the participation levels of that sport.4 “Severity” could be described using six criteria: (i) nature of sports injury, (ii) duration and nature of treatment, (iii) sporting time lost, (iv) working time lost (of the injured individual or injured individual’s parent/legal guardian), (v) permanent damage and (vi) monetary cost.4 In general, rugby carries a higher incidence and severity of injury to the participant,5 in comparison to other popular sports.6 Although other sports,7–9 including rugby league,10–12 have reported on injury-related monetary costs, this analysis is yet to be performed in rugby union. Besides being an important descriptor of severity, the monetary cost of injury provides valuable information to drive and evaluate the effectiveness of preventative measures.8 In South Africa, the BokSmart programme is responsible for implementing injury prevention strategies in rugby union13 and information on the costs of
http://dx.doi.org/10.1016/j.jsams.2014.06.015 1440-2440/© 2014 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.
J.C. Brown et al. / Journal of Science and Medicine in Sport 18 (2015) 394–399
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Fig. 1. A flow diagram illustrating the number of players that were considered for this study. Although there were 3652 players at these tournaments, only 2% (n = 71) sought follow-up treatment after the tournament conclusion.
injuries is therefore essential for guiding future policies emanating from this nationwide programme. Therefore, the aim of this study is to describe the monetary cost of rugby-related injuries in a youth cohort.
2. Methods The population studied included the combined attendees of the South African Rugby Union (SARU) Youth Weeks in 2011 and 2012, and, depending on the tournament, players ranged between the ages of 12 and 18 years old. These tournaments showcase the most talented players in each age group, and have been described in more detail elsewhere.14 Written informed consent was provided by the player or by the player’s parent/legal guardian if the player was younger than 18 years of age. All information was recorded on a SARU database to which the authors were granted access by SARU and the UCT Human Research Ethics Committee. In total, 3652 players attended the four elite national youth tournaments: Craven Week under-13, Grant Khomo under-16, Academy Week under-18 and Craven Week under-18 in 2011 and 2012 (Fig. 1). Although preliminary analyses indicated no differences in injury rates, the tournaments were analysed separately by age group for the purposes of this study: “under-13” (Craven Week under-13 tournament), “under-16” (Grant Khomo under-16 tournament) and “under-18” (combination of Craven Week and Academy Week under-18 tournaments). Of these players, 12% (421 players) received medical attention from the SARU tournament Doctor and accounted for a total of 436 injury events. Of the 421 injured players, 17% (n = 71 players) sought further treatment after the tournament. The data collection process has been discussed previously.14 Briefly, SARU collected data on all 421 injured players that were attended to by the tournament medical doctors in 2011 and 2012. The injury definitions, including that of what constituted a “timeloss” (TL) injury were consistent with the consensus statement for injury surveillance in rugby union15 with slight adjustments for these tournaments. The injury definition was: “Any physical complaint, which was caused by a transfer of energy that exceeded the body’s ability to maintain its structural and/or functional integrity, that was sustained by a player during a rugby match and required attention from the SARU Tournament Doctor, irrespective of who decided this”. Therefore, a time-loss (TL) injury was an injury that resulted in the player being absent from more than one match in a tournament, or more than one day of normal/planned recreational activities after the tournament. After the tournament ended and the injured players returned home, the responsibility of the treatment and rehabilitation of their injuries resided with the players’ parents/legal guardians. Players that were confirmed or suspected by the tournament medical doctors to have suffered a TL injury at the tournaments were followed up telephonically (Fig. 1). Costs were estimated from the perspective of the medical insurer in South Africa.
An “old” injury was one in which the player answered “yes” to the following question, asked by the tournament Doctor, or data capturer, or both: “Have you ever had this injury before?”. If the player answered “no” to the question, the injury was classified as “new”. The consensus statement severity of injury categories15 of slight, minimal and mild, were grouped together as “mild”, and compared to “moderate” and “severe” categories due to a lack of statistical power. The parents/legal guardians of all players with confirmed and suspected time-loss (including “unsure” diagnoses) injuries (n = 190) were contacted a week after the completion of the tournament (Fig. 1). Of these 190 injured players, 7% (n = 14 of 190) could not be followed up due to incorrect contact details or no response to these follow-up calls (“no contact” in Fig. 1) and 3% (n = 5 of 190) were re-classified as medical attention injuries, leaving 171 timeloss injuries.14 Of the 171 injured players that were contacted, 42% (n = 71) sought follow-up treatment after the tournament (“followup injuries”). Only the medical treatments that were sought after the tournament (i.e. excluding the Tournament Doctor’s treatment) were included in these analyses. Medical treatments/services and the time that the injured player’s parent/legal guardian were away from work were quantified using a cost diary used previously,8 and which was adapted for use in South Africa. The South African version was adapted from the original version to provide a semi-structured guide for the telephonic interviewer to capture total quantity and type of medical service sought. Direct costs (medical care quantification) were initially estimated in South African Rand (R) for all medical treatments. Indirect costs could not be calculated due to the wide range in average salaries in South Africa. Thereafter, costs were converted to US dollars (US$) based on purchasing power parities (PPP’s), as suggested for economic evaluations.16 To convert R to US$, the R value should be divided by a factor of 5.48: this factor was obtained from the most recent World Bank estimates, which were last provided in 2012.17 Discovery Health Insurance, one of the largest private medical insurance companies in South Africa, provided cost estimates for medical consultations. This approach was adopted due to South Africa not having any national standard medical care costs available at the time of the study. Inferred costs were calculated based on the medical insurance company’s 2013 data even though the actual treatments occurred in 2011 and 2012. Discovery Health based their care cost estimates on historical data of the medical insurance company for a given region within a specific diagnosis-related group. These rates were based on 2006 national rates (the last time standard rates were available) and included inflation adjustments, time factors, difficulty in receiving treatment, and thousands of claims factored into the estimation. Medical care costs may vary depending on the type of injury and initial consultations sometimes differ in price from the follow-up treatments (rehabilitation).
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Table 1 The injury rate (per 1000 h of tournament play), type of injury and proportion of injured players with medical insurance for the 2011 and 2012 tournaments (n = 3652).
All injuries (n = 436) Injury rate (95% CIs) Injury type – % (n = 436) Concussion Bruise/contusion Broken bone/fracture Joint/Lig./Ten. Laceration/abrasion Muscle strain/cramp Unsure/other TL Injuries (n = 171) Injury rate (95% CIs) Injury type – % (n = 171) Concussion Bruise/contusion Broken bone/fracture Joint/Lig./Ten. Laceration/abrasion Muscle strain/cramp Unsure/other
Under-13
Under-16
Under-18
Combined
64.6 (51.5–77.7)
54.4 (43.3–65.4)
52.1 (45.7–58.6)
54.6 (49.5–59.8)
9% (n = 8) 31% (n = 29) 8% (n = 7) 22% (n = 20) 4% (n = 4) 19% (n = 18) 8% (n = 7) 22.2 (14.5–29.9)
13% (n = 12) 13% (n = 12) 2% (n = 2) 32% (n = 30) 15% (n = 14) 12% (n = 11) 13% (n = 12) 22.2 (15.2–29.3)
11% (n = 27) 18% (n = 45) 4% (n = 9) 33% (n = 83) 12% (n = 31) 14% (n = 36) 8% (n = 19) 21.1 (17.0–25.2)
11% (n = 47) 20% (n = 86) 4% (n = 18) 31% (n = 133) 11% (n = 49) 15% (n = 65) 9% (n = 38) 21.4 (18.2–24.6)
19% (n = 6) 19% (n = 6) 22% (n = 7) 22% (n = 7) 3% (n = 1) 16% (n = 5) 0% (n = 0)
29% (n = 11) 11% (n = 4) 5% (n = 2) 39% (n = 15) 5% (n = 2) 5% (n = 2) 5% (n = 2)
27% (n = 27) 6% (n = 6) 8% (n = 8) 40% (n = 40) 6% (n = 6) 8% (n = 8) 6% (n = 6)
26% (n = 44) 9% (n = 16) 10% (n = 7) 36% (n = 62) 5% (n = 9) 9% (n = 15) 5% (n = 8)
Under-13 – Craven Week under-13, Under-16 – Grant Khomo under-16, Under-18 – Academy Week under-18 + CW18 – Craven Week under-18 combined, CIs – confidence intervals, IID – injury incidence densities, TL – time-loss, Med. – medical, Lig. – ligament, Ten. – tendon.
Surgeries were assumed to be conditions without major complications – e.g. basic shoulder/clavicle injury with basic reduction and repair. Therapy (Physiotherapy, Occupational Therapy, Biokinetics) costs were based on the most likely modalities related to the particular injury type (e.g. muscle strain or ligament tear). For radiology costs, the x-rays and scans were assumed to be uncontrasted (i.e. basic evaluations). Dental cases were considered to be basic examinations as not enough information was available. Total costs were calculated based on the initial rate for a particular medical service and medical service provider and multiplied by the frequency of these visits. The parents’ missed work could not be converted into a financial cost due to the large rates of unemployment and variance in average wages in South Africa. As costs were not normally distributed, mean differences in costs and associated 95% Confidence Intervals were obtained by bias corrected and accelerated bootstrapping (2000 replications). All analyses were performed with IBM SPSS statistical software (Version 21). Differences in costs were compared between categories using 95% confidence intervals.15
3. Results The overall injury rates (Table 1) were not significantly different between the various age groups (under-13 to under-18), with a combined rate of 54.6 injuries per 1000 h (95% CIs: 49.5–59.8 injuries per 1000 h) of tournament play resulting from 436 injury events in 7945 exposure hours. Of the 436 injury events, the most common injury was a joint/ligament/tendon injury which accounted for 31% of all injuries. The joint/ligament/tendon injuries were the most common at all age groups except for under-13 where bruises/contusions were the most common type of injury (31%). Of the 421 players who received medical attention and agreed to answer the question (n = 388), 25% (n = 97) did not have medical insurance. The overall confirmed time-loss injury rate was 21.4 injuries per 1000 h (95% CIs: 18.2–24.6). Similarly to all injuries, joint/ligament/tendon injuries accounted for the highest proportion (36%) of all TL injuries, overall. This was consistent for all the age groups. Of the 71 players that sought and received treatment once returning home (Table 1), the largest proportion was from the under-18 age group (n = 48; 68%). Overall, 26% (n = 18 of 69; 2 did
not answer) of these players did not have medical insurance. The highest proportions of these injured players with no medical insurance were at the under-18 age group (61%, n = 11 of 18). The most expensive unit costs of medical treatment (Supplemental Table 1) were the hospital/surgery costs which ranged from US$1066 (per day) for the Intensive Care Unit (ICU) to US$8421 for surgery to the lower extremities. Other large costs included MRI/CT scans of various joints (range US$393–US$1038). Supplementary Table 1 related to this article can be found, in the online version, at doi:10.1016/j.jsams.2014.06.015. In total, there were 390 treatments that amounted to an estimated total cost of US$80 228. Of the 390 medical treatments (Supplemental Table 1), the most common category of treatment was “consultations and rehabilitations” (87%, n = 340 of 390), of which General Practitioner consultations accounted for the largest proportion (18%, n = 60). Despite accounting for the largest proportion of treatments (87%), this category of “consultations and rehabilitations” only accounted for 26% of the total costs of all treatments. In contrast, the “hospital/surgery” category only accounted for 3% (n = 11 of 390) of all treatments sought, yet accounted for 66% of the total treatment costs (US$52 787 of US$80 228). Follow-up injuries cost the 71 players, on average, US$731 per follow-up injury (95% CIs: US$425–US$1096) (Table 2). These follow-up costs would be, on average, US$123 per injured player or US$14 per tournament player (Table 2). While the younger under13 and under-16 age groups had a tendency to be more expensive than the under-18 age group, these average costs were not significantly different from one another (Table 2). Injuries of “mild” severity (US$217, 95% CIs: US$122–US$321), cost on average, significantly less than injuries with a “severe” severity (US$1551, 95% CIs: US$655–US$2696). Injuries to the lower extremities (US$278, 95% CIs: US$217–US$342) cost significantly less than those to the upper extremities (US$1242, 95% CIs: US$446–US$2269), on average, and injuries to the head/face (US$822, 95% CIs: US$168–US$1825) and to the neck/cervical/back regions (US$480, CIs could not be calculated) fell between the costs to the lower and upper extremities. On average, fractures (US$2609, 95% CIs: US$864–US$4605) were the most expensive type of injury to treat. This treatment cost was significantly greater than the cost of treating muscle injuries (US$261, 95% CIs: US$134–US$426), on average. Also, players with medical insurance had significantly greater treatment costs (US$937, 95% CIs: US$486–US$1500) than those players without medical insurance (US$220, 95% CIs: US$145–US$302).
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Table 2 Mean costs for the 71 players seeking treatment after the four tournaments; divided according to age group, injury sites, injury types, injury severity, injury nature and medical insurance status (n = 71). N
Costs per population Costs per playera Costs per injurya Costs per follow-up injurya
Mean cost
95% confidence interval
(US$f )
Lower
Upper
3652 421 71
14 123 731
8 66 425
22 195 1096
Age group Under-13 Under-16 Under-18
14 9 48
1743 774 428
298 186 232
3519 1517 736
Injury Severity “Mild”b “Moderate” “Severe”b
14 34 21
217 296 1551
122 188 655
321 421 2696
Injury site Lower extremityc Upper extremityc Head/face Neck/cervical/back
26 24 14 7
278 1242 822 480
217 446 168 –
342 2269 1825 –
Injury type Concussion Contusion Fractured Joint/ligament/tendon Laceration Muscle straind Unsure/Other
7 3 11 29 5 9 7
358 240 2609 522 65 261 311
– – 864 232 – 134 –
– – 4605 962 – 426 –
Injury nature New injury Old injury
51 19
786 608
372 214
1307 1235
Medical Insurance Yese Noe
51 18
937 220
486 145
1500 302
a b c d e f
Costs per player, costs per injury and costs per follow-up injury were all significantly different from each other. “Mild” severity significantly different to “severe” severity category. Lower extremity injuries significantly different to upper extremity injuries. Fracture injuries significantly different to muscle injuries. Injured players without medical insurance (“No”) significantly different to players with medical insurance (“Yes”). Conversion: local currency (ZAR)/5.48 to obtain US$ at purchasing power parity (PPP) rate: obtained from World Bank in March 2014.17
In total, n = 13 parents/guardians reported missing work to ensure their child received follow-up treatment. In total, these parents missed 26 work days (8 h work day) at a median of 0.5 days (Minimum: 0.1 day–Maximum: 9 days) per parent. 4. Discussion The main finding of this paper was that the monetary cost to players seeking follow-up treatment was, on average US$731 (95% CIs: US$425–US$1096). These high costs were incurred by a relative minority of players: 17% (n = 71 of 421) of injured players and 2% (n = 71 of 3652) of the total tournament players. If these costs were divided by all the tournament players (n = 3652) instead of just those that sought follow-up treatment, the costs would be less of a burden (US$14 instead of US$731, on average). Furthermore, the highest costs were for injuries of “severe” nature (based on timeloss definition), upper extremity injuries, fractures and for players who had medical insurance (in comparison to those that did not). The average cost per tournament player of the present study (US$14) is, as expected, far less than the annual medical costs reported for a high school population of athletes in 1999 (US$187 per registered athlete).7 However, only players with time-loss injuries who actively sought medical treatment above and beyond what was already provided at the rugby tournament were included in the present study, so this finding was not surprising. Also, the
average cost per follow-up injury in the present study (US$731) was about ten times less than moderate to serious injuries reported for rugby league between 1999 and 2007 (US$7100),18 although the rugby league study included players of all ages, not just youth. The finding that the injuries with the longest periods of recovery (more than 28 days = “severe”) were also the most expensive was expected and is consistent with findings in a population of high school sports participants in the United States.7 Severe injuries in the present study (US$1551) also cost much less than in the study of high school sports (US$35 336).7 The very different study designs could explain the discrepancies between the two studies. Nonetheless, the findings of the present study indicate an additional burden of injury that has not been identified in a youth rugby union cohort before, i.e. the economic burden of injury of player’s that seek follow-up treatment. For player’s seeking follow-up treatment this was, on average, US$731 and a median of 0.5 missed work days per injury for the parent/legal guardian. The higher average costs of upper extremity injuries in comparison to lower extremity injuries was unexpected and in contrast to what has been found in rugby league players of all ages,18 but was not dissimilar to general physical activity and sport injuries in children aged 10–12 years.8 The costs for both of these sites (upper and lower extremity) were greater in the present study than in that of rugby league players that involved all ages and both sexes. However, injury sites were not corrected for the possible confounding
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effect of injury type – therefore we cannot exclude the possibility that the significantly higher average cost of fractures (Table 2) could have influenced the mean cost of injury sites in the present study. The finding of higher average costs of fractures, in comparison to other injury sites in the present study was also in contrast with a rugby league report of all ages18 and study on knee injuries in Swiss youth sports.19 The average cost of fractures in the present study (US$2609) was also over 5 times greater than in the rugby league study (US$469).18 The relatively low average cost of head/neck injuries and, specifically, concussions in the present study (US$358) (Table 2) is surprising and in less than 70 times the cost in the rugby league study of all ages in New Zealand (US$25 347).18 Rugby league has comparable rates of concussion to rugby union and thus this difference could not be explained by injury rates between the two sports (Table 1).20 Of concern is that the low treatment costs associated with concussions in the present study could indicate that players did not consult a medical doctor or follow the correct return-to-play guidelines, which are considered “best-practice”21 and are strongly advocated by BokSmart/SARU for players with concussion.13 In fact, only 14% of all concussions (n = 7 of 50) received any form of follow-up treatment. Another explanation could be that the first-line medical professionals involved in assessing the concussed players both with medical aid, and especially those concussed players without medical aid, might also not be appropriately versed in the current scientific literature and medical protocols for correctly identifying, suspecting, diagnosing, treating and managing concussed players for safe return to play.22 This potential phenomenon of inadequate medical care could partially explain the finding that players with medical insurance had, on average, higher treatment costs than those players without medical aid: it is possible that those players without medical insurance did not receive optimal care for their injuries. In South Africa, access to medical insurance is linked to socioeconomic status and determines how one deals with a manageable disease such as hypertension.23 It is also possible that players with medical insurance could have received more treatment than was necessary for a particular injury. Thus, it is further possible that the absence or presence of medical insurance could have affected follow-up treatment-seeking behaviour. Although there were no significant differences in mean costs sustained in the different age groups (Table 2), this was expected due to the similar injury rates of the three age groups (Table 1). These findings support a study of high school sports participants in North Carolina, where age was also not considered a risk factor for the cost of injury albeit that age was categorised differently to that of the present study which based it’s categorisation on tournaments.7 Similarly, there was no significant difference in mean costs for players who did, or did not, mention having previously had the injury they were treated for – this phenomenon was also observed in the North Carolina High School study.7 However, comparable costs indicate that the costs for the present study might be greater than that of the North Carolina high school study in general. For example, the average medical cost of football-related injuries was $577 in the North Carolina high school study, while the comparable cost per injury for the present study was $731. A possible limitation of the present study was that only the 190 players who suffered what the tournament doctor predicted to be a “time-loss” injury were followed-up. This decision was made for logistical reasons as it would have been difficult to accurately follow-up all medical attention injuries telephonically. However, it is unlikely that many medical attention injuries required follow-up treatment. The cost estimations were based on numerous assumptions by the medical insurance company due to the unique situation in South Africa in which there is no prescribed standard rate for medical treatment costs. Thus, although the present method is
subject to potential inaccuracies as a result of these assumptions, the authors contend that any method of calculating costs in South Africa would require many assumptions. This approach of using an insurer to estimate costs also meant that the raw data were not available for conducting sensitivity analyses, which may limit the comparability of these findings to other countries although the unit cost and frequency of care (Supplementary material Table 1) should provide some allowance for comparison. Owing to the large discrepancy in average wage in South Africa, the authors were unable to estimate an indirect cost for the loss of the working time of the parents who had to take time off work to accompany their children to the health care practitioner. The classification of “old” or previous injury was also highly subjective, although it was difficult to implement a repeatable objective assessment in the circumstances in which these data were collected. Mean injury costs should have been corrected for different proportions of types of injuries (e.g. fractures, strains, etc.) in the different tournaments, but the study was statistically underpowered to be able to perform these analyses. Finally, comparisons between the present findings and other studies were limited due to a paucity of economic studies that investigated male youth athletes. 5. Conclusion Although the estimation of costs associated with the medical treatments described in the present study involved many assumptions due to the circumstances in which they were collected, this study is the first to quantify and compare monetary cost as an indication of injury burden in youth rugby union. In particular BokSmart, the national injury prevention programme in South Africa,13 should consider the high monetary costs of fractures and upper extremity injuries, in addition to injuries of large severity which have previously been identified.14 Furthermore, this study indicated the potential to significantly reduce the direct burden of injury to injured players, by dividing predicted injury costs amongst all players attending these tournaments, instead of just the relative minority who suffered an injury requiring follow-up treatment. This proposed model could potentially alleviate and offset individual injury costs at these types of tournaments, regardless of medical insurance status. Practical implications • This study describes the monetary cost of rugby union injuries of youth rugby players in South Africa seeking follow-up treatment for injuries sustained at national tournaments. • The costs are estimated from a health insurer’s perspective and thus are a conservative estimate of what these injuries could cost the parents/legal guardians of the injured players. • As the monetary costs of these injuries can be high, a description of injury severity/burden might be incomplete without this aspect of injury severity. • Players with long time-loss periods, and those suffering upper extremity injuries and fractures have high costs of injury. • Players suffering concussion and those without medical aid (insurance) may not be seeking adequate medical care before returning to play, which could predispose them to re-injury. Acknowledgments The authors would like to thank Ms Jill Borreson and Ms Kirsten Blair from Discovery Health for their assistance in calculating the medical costs related to these injuries and the treatments associated with the particular injuries.
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Contents lists available at ScienceDirect
Journal of Science and Medicine in Sport journal homepage: www.elsevier.com/locate/jsams
Original research
The economic burden of time-loss injuries to youth players participating in week-long rugby union tournaments James C. Brown b,a,∗ , Wayne Viljoen c , Mike I. Lambert a , Clint Readhead c , Chelsea Fuller a , Willem Van Mechelen b,a , Evert Verhagen b a UCT/MRC Research Unit for Exercise Science and Sports Medicine, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa b Department of Public and Occupational Health, EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands c South African Rugby Union (SARU), Cape Town, South Africa
a r t i c l e
i n f o
Article history: Received 6 December 2013 Received in revised form 27 June 2014 Accepted 29 June 2014 Available online 16 July 2014 Keywords: Football Football/economics Football/economics/cost analysis Football/injuries (MeSH terms)
a b s t r a c t Objectives: Rugby Union (“rugby”) is a popular sport with high injury risk. Burden of injury is described by the incidence and severity of injury. However reports have ignored the monetary cost of injuries. Therefore the aim of this study was to describe the monetary cost associated with youth rugby injuries. Design: This descriptive study quantified medical treatments of injured players at the South African Rugby Union Youth tournaments in 2011/2012 and the days of work parents missed as a result of the injuries. A health insurer used these data to calculate associated costs. Methods: Legal guardians of the 421 injured players were contacted telephonically on a weekly basis until they returned to play. Treatments costs were estimated in South African Rands based on 2013 insurance rates and converted to US$ using purchasing power parities. Results: Of the 3652 players, 2% (n = 71) sought medical care after the tournament. For these players, average treatment costs were high (US$731 per player, 95% CI: US$425–US$1096), with fractures being the most expensive type of injury. Players with medical insurance had higher costs (US$937, 95% CI: US$486–US$1500) than those without (US$220, 95% CI: US$145–US$302). Conclusions: Although a minority of players sought follow-up treatment after the tournaments, the cost of these injuries was high. Players without medical insurance having lower costs may indicate that these players did not receive adequate treatment for their injuries. Injury prevention efforts should consider injuries with high costs and the treatment of players without medical insurance. © 2014 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.
1. Introduction Participation in physical activity has numerous health benefits for children.1 However, physical activity can also pose the risk of health detriments, such as injury, the likelihood of which may vary depending on the mode of physical activity.2 This potential burden of injury may discourage participation in a particular sport, unless preventative measures are introduced effectively.2 Of all international sports, Rugby union (“rugby”) is arguably amongst the most popular, for all age groups, including youth.3 To better understand the injury problem, both the incidence and severity of a particular sport-related injury need to be accurately
∗ Corresponding author. E-mail addresses: [email protected], [email protected] (J.C. Brown).
quantified.2 The incidence of injury can be described by calculating the number of new injuries that occur taking into account the participation levels of that sport.4 “Severity” could be described using six criteria: (i) nature of sports injury, (ii) duration and nature of treatment, (iii) sporting time lost, (iv) working time lost (of the injured individual or injured individual’s parent/legal guardian), (v) permanent damage and (vi) monetary cost.4 In general, rugby carries a higher incidence and severity of injury to the participant,5 in comparison to other popular sports.6 Although other sports,7–9 including rugby league,10–12 have reported on injury-related monetary costs, this analysis is yet to be performed in rugby union. Besides being an important descriptor of severity, the monetary cost of injury provides valuable information to drive and evaluate the effectiveness of preventative measures.8 In South Africa, the BokSmart programme is responsible for implementing injury prevention strategies in rugby union13 and information on the costs of
http://dx.doi.org/10.1016/j.jsams.2014.06.015 1440-2440/© 2014 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.
J.C. Brown et al. / Journal of Science and Medicine in Sport 18 (2015) 394–399
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Fig. 1. A flow diagram illustrating the number of players that were considered for this study. Although there were 3652 players at these tournaments, only 2% (n = 71) sought follow-up treatment after the tournament conclusion.
injuries is therefore essential for guiding future policies emanating from this nationwide programme. Therefore, the aim of this study is to describe the monetary cost of rugby-related injuries in a youth cohort.
2. Methods The population studied included the combined attendees of the South African Rugby Union (SARU) Youth Weeks in 2011 and 2012, and, depending on the tournament, players ranged between the ages of 12 and 18 years old. These tournaments showcase the most talented players in each age group, and have been described in more detail elsewhere.14 Written informed consent was provided by the player or by the player’s parent/legal guardian if the player was younger than 18 years of age. All information was recorded on a SARU database to which the authors were granted access by SARU and the UCT Human Research Ethics Committee. In total, 3652 players attended the four elite national youth tournaments: Craven Week under-13, Grant Khomo under-16, Academy Week under-18 and Craven Week under-18 in 2011 and 2012 (Fig. 1). Although preliminary analyses indicated no differences in injury rates, the tournaments were analysed separately by age group for the purposes of this study: “under-13” (Craven Week under-13 tournament), “under-16” (Grant Khomo under-16 tournament) and “under-18” (combination of Craven Week and Academy Week under-18 tournaments). Of these players, 12% (421 players) received medical attention from the SARU tournament Doctor and accounted for a total of 436 injury events. Of the 421 injured players, 17% (n = 71 players) sought further treatment after the tournament. The data collection process has been discussed previously.14 Briefly, SARU collected data on all 421 injured players that were attended to by the tournament medical doctors in 2011 and 2012. The injury definitions, including that of what constituted a “timeloss” (TL) injury were consistent with the consensus statement for injury surveillance in rugby union15 with slight adjustments for these tournaments. The injury definition was: “Any physical complaint, which was caused by a transfer of energy that exceeded the body’s ability to maintain its structural and/or functional integrity, that was sustained by a player during a rugby match and required attention from the SARU Tournament Doctor, irrespective of who decided this”. Therefore, a time-loss (TL) injury was an injury that resulted in the player being absent from more than one match in a tournament, or more than one day of normal/planned recreational activities after the tournament. After the tournament ended and the injured players returned home, the responsibility of the treatment and rehabilitation of their injuries resided with the players’ parents/legal guardians. Players that were confirmed or suspected by the tournament medical doctors to have suffered a TL injury at the tournaments were followed up telephonically (Fig. 1). Costs were estimated from the perspective of the medical insurer in South Africa.
An “old” injury was one in which the player answered “yes” to the following question, asked by the tournament Doctor, or data capturer, or both: “Have you ever had this injury before?”. If the player answered “no” to the question, the injury was classified as “new”. The consensus statement severity of injury categories15 of slight, minimal and mild, were grouped together as “mild”, and compared to “moderate” and “severe” categories due to a lack of statistical power. The parents/legal guardians of all players with confirmed and suspected time-loss (including “unsure” diagnoses) injuries (n = 190) were contacted a week after the completion of the tournament (Fig. 1). Of these 190 injured players, 7% (n = 14 of 190) could not be followed up due to incorrect contact details or no response to these follow-up calls (“no contact” in Fig. 1) and 3% (n = 5 of 190) were re-classified as medical attention injuries, leaving 171 timeloss injuries.14 Of the 171 injured players that were contacted, 42% (n = 71) sought follow-up treatment after the tournament (“followup injuries”). Only the medical treatments that were sought after the tournament (i.e. excluding the Tournament Doctor’s treatment) were included in these analyses. Medical treatments/services and the time that the injured player’s parent/legal guardian were away from work were quantified using a cost diary used previously,8 and which was adapted for use in South Africa. The South African version was adapted from the original version to provide a semi-structured guide for the telephonic interviewer to capture total quantity and type of medical service sought. Direct costs (medical care quantification) were initially estimated in South African Rand (R) for all medical treatments. Indirect costs could not be calculated due to the wide range in average salaries in South Africa. Thereafter, costs were converted to US dollars (US$) based on purchasing power parities (PPP’s), as suggested for economic evaluations.16 To convert R to US$, the R value should be divided by a factor of 5.48: this factor was obtained from the most recent World Bank estimates, which were last provided in 2012.17 Discovery Health Insurance, one of the largest private medical insurance companies in South Africa, provided cost estimates for medical consultations. This approach was adopted due to South Africa not having any national standard medical care costs available at the time of the study. Inferred costs were calculated based on the medical insurance company’s 2013 data even though the actual treatments occurred in 2011 and 2012. Discovery Health based their care cost estimates on historical data of the medical insurance company for a given region within a specific diagnosis-related group. These rates were based on 2006 national rates (the last time standard rates were available) and included inflation adjustments, time factors, difficulty in receiving treatment, and thousands of claims factored into the estimation. Medical care costs may vary depending on the type of injury and initial consultations sometimes differ in price from the follow-up treatments (rehabilitation).
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Table 1 The injury rate (per 1000 h of tournament play), type of injury and proportion of injured players with medical insurance for the 2011 and 2012 tournaments (n = 3652).
All injuries (n = 436) Injury rate (95% CIs) Injury type – % (n = 436) Concussion Bruise/contusion Broken bone/fracture Joint/Lig./Ten. Laceration/abrasion Muscle strain/cramp Unsure/other TL Injuries (n = 171) Injury rate (95% CIs) Injury type – % (n = 171) Concussion Bruise/contusion Broken bone/fracture Joint/Lig./Ten. Laceration/abrasion Muscle strain/cramp Unsure/other
Under-13
Under-16
Under-18
Combined
64.6 (51.5–77.7)
54.4 (43.3–65.4)
52.1 (45.7–58.6)
54.6 (49.5–59.8)
9% (n = 8) 31% (n = 29) 8% (n = 7) 22% (n = 20) 4% (n = 4) 19% (n = 18) 8% (n = 7) 22.2 (14.5–29.9)
13% (n = 12) 13% (n = 12) 2% (n = 2) 32% (n = 30) 15% (n = 14) 12% (n = 11) 13% (n = 12) 22.2 (15.2–29.3)
11% (n = 27) 18% (n = 45) 4% (n = 9) 33% (n = 83) 12% (n = 31) 14% (n = 36) 8% (n = 19) 21.1 (17.0–25.2)
11% (n = 47) 20% (n = 86) 4% (n = 18) 31% (n = 133) 11% (n = 49) 15% (n = 65) 9% (n = 38) 21.4 (18.2–24.6)
19% (n = 6) 19% (n = 6) 22% (n = 7) 22% (n = 7) 3% (n = 1) 16% (n = 5) 0% (n = 0)
29% (n = 11) 11% (n = 4) 5% (n = 2) 39% (n = 15) 5% (n = 2) 5% (n = 2) 5% (n = 2)
27% (n = 27) 6% (n = 6) 8% (n = 8) 40% (n = 40) 6% (n = 6) 8% (n = 8) 6% (n = 6)
26% (n = 44) 9% (n = 16) 10% (n = 7) 36% (n = 62) 5% (n = 9) 9% (n = 15) 5% (n = 8)
Under-13 – Craven Week under-13, Under-16 – Grant Khomo under-16, Under-18 – Academy Week under-18 + CW18 – Craven Week under-18 combined, CIs – confidence intervals, IID – injury incidence densities, TL – time-loss, Med. – medical, Lig. – ligament, Ten. – tendon.
Surgeries were assumed to be conditions without major complications – e.g. basic shoulder/clavicle injury with basic reduction and repair. Therapy (Physiotherapy, Occupational Therapy, Biokinetics) costs were based on the most likely modalities related to the particular injury type (e.g. muscle strain or ligament tear). For radiology costs, the x-rays and scans were assumed to be uncontrasted (i.e. basic evaluations). Dental cases were considered to be basic examinations as not enough information was available. Total costs were calculated based on the initial rate for a particular medical service and medical service provider and multiplied by the frequency of these visits. The parents’ missed work could not be converted into a financial cost due to the large rates of unemployment and variance in average wages in South Africa. As costs were not normally distributed, mean differences in costs and associated 95% Confidence Intervals were obtained by bias corrected and accelerated bootstrapping (2000 replications). All analyses were performed with IBM SPSS statistical software (Version 21). Differences in costs were compared between categories using 95% confidence intervals.15
3. Results The overall injury rates (Table 1) were not significantly different between the various age groups (under-13 to under-18), with a combined rate of 54.6 injuries per 1000 h (95% CIs: 49.5–59.8 injuries per 1000 h) of tournament play resulting from 436 injury events in 7945 exposure hours. Of the 436 injury events, the most common injury was a joint/ligament/tendon injury which accounted for 31% of all injuries. The joint/ligament/tendon injuries were the most common at all age groups except for under-13 where bruises/contusions were the most common type of injury (31%). Of the 421 players who received medical attention and agreed to answer the question (n = 388), 25% (n = 97) did not have medical insurance. The overall confirmed time-loss injury rate was 21.4 injuries per 1000 h (95% CIs: 18.2–24.6). Similarly to all injuries, joint/ligament/tendon injuries accounted for the highest proportion (36%) of all TL injuries, overall. This was consistent for all the age groups. Of the 71 players that sought and received treatment once returning home (Table 1), the largest proportion was from the under-18 age group (n = 48; 68%). Overall, 26% (n = 18 of 69; 2 did
not answer) of these players did not have medical insurance. The highest proportions of these injured players with no medical insurance were at the under-18 age group (61%, n = 11 of 18). The most expensive unit costs of medical treatment (Supplemental Table 1) were the hospital/surgery costs which ranged from US$1066 (per day) for the Intensive Care Unit (ICU) to US$8421 for surgery to the lower extremities. Other large costs included MRI/CT scans of various joints (range US$393–US$1038). Supplementary Table 1 related to this article can be found, in the online version, at doi:10.1016/j.jsams.2014.06.015. In total, there were 390 treatments that amounted to an estimated total cost of US$80 228. Of the 390 medical treatments (Supplemental Table 1), the most common category of treatment was “consultations and rehabilitations” (87%, n = 340 of 390), of which General Practitioner consultations accounted for the largest proportion (18%, n = 60). Despite accounting for the largest proportion of treatments (87%), this category of “consultations and rehabilitations” only accounted for 26% of the total costs of all treatments. In contrast, the “hospital/surgery” category only accounted for 3% (n = 11 of 390) of all treatments sought, yet accounted for 66% of the total treatment costs (US$52 787 of US$80 228). Follow-up injuries cost the 71 players, on average, US$731 per follow-up injury (95% CIs: US$425–US$1096) (Table 2). These follow-up costs would be, on average, US$123 per injured player or US$14 per tournament player (Table 2). While the younger under13 and under-16 age groups had a tendency to be more expensive than the under-18 age group, these average costs were not significantly different from one another (Table 2). Injuries of “mild” severity (US$217, 95% CIs: US$122–US$321), cost on average, significantly less than injuries with a “severe” severity (US$1551, 95% CIs: US$655–US$2696). Injuries to the lower extremities (US$278, 95% CIs: US$217–US$342) cost significantly less than those to the upper extremities (US$1242, 95% CIs: US$446–US$2269), on average, and injuries to the head/face (US$822, 95% CIs: US$168–US$1825) and to the neck/cervical/back regions (US$480, CIs could not be calculated) fell between the costs to the lower and upper extremities. On average, fractures (US$2609, 95% CIs: US$864–US$4605) were the most expensive type of injury to treat. This treatment cost was significantly greater than the cost of treating muscle injuries (US$261, 95% CIs: US$134–US$426), on average. Also, players with medical insurance had significantly greater treatment costs (US$937, 95% CIs: US$486–US$1500) than those players without medical insurance (US$220, 95% CIs: US$145–US$302).
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Table 2 Mean costs for the 71 players seeking treatment after the four tournaments; divided according to age group, injury sites, injury types, injury severity, injury nature and medical insurance status (n = 71). N
Costs per population Costs per playera Costs per injurya Costs per follow-up injurya
Mean cost
95% confidence interval
(US$f )
Lower
Upper
3652 421 71
14 123 731
8 66 425
22 195 1096
Age group Under-13 Under-16 Under-18
14 9 48
1743 774 428
298 186 232
3519 1517 736
Injury Severity “Mild”b “Moderate” “Severe”b
14 34 21
217 296 1551
122 188 655
321 421 2696
Injury site Lower extremityc Upper extremityc Head/face Neck/cervical/back
26 24 14 7
278 1242 822 480
217 446 168 –
342 2269 1825 –
Injury type Concussion Contusion Fractured Joint/ligament/tendon Laceration Muscle straind Unsure/Other
7 3 11 29 5 9 7
358 240 2609 522 65 261 311
– – 864 232 – 134 –
– – 4605 962 – 426 –
Injury nature New injury Old injury
51 19
786 608
372 214
1307 1235
Medical Insurance Yese Noe
51 18
937 220
486 145
1500 302
a b c d e f
Costs per player, costs per injury and costs per follow-up injury were all significantly different from each other. “Mild” severity significantly different to “severe” severity category. Lower extremity injuries significantly different to upper extremity injuries. Fracture injuries significantly different to muscle injuries. Injured players without medical insurance (“No”) significantly different to players with medical insurance (“Yes”). Conversion: local currency (ZAR)/5.48 to obtain US$ at purchasing power parity (PPP) rate: obtained from World Bank in March 2014.17
In total, n = 13 parents/guardians reported missing work to ensure their child received follow-up treatment. In total, these parents missed 26 work days (8 h work day) at a median of 0.5 days (Minimum: 0.1 day–Maximum: 9 days) per parent. 4. Discussion The main finding of this paper was that the monetary cost to players seeking follow-up treatment was, on average US$731 (95% CIs: US$425–US$1096). These high costs were incurred by a relative minority of players: 17% (n = 71 of 421) of injured players and 2% (n = 71 of 3652) of the total tournament players. If these costs were divided by all the tournament players (n = 3652) instead of just those that sought follow-up treatment, the costs would be less of a burden (US$14 instead of US$731, on average). Furthermore, the highest costs were for injuries of “severe” nature (based on timeloss definition), upper extremity injuries, fractures and for players who had medical insurance (in comparison to those that did not). The average cost per tournament player of the present study (US$14) is, as expected, far less than the annual medical costs reported for a high school population of athletes in 1999 (US$187 per registered athlete).7 However, only players with time-loss injuries who actively sought medical treatment above and beyond what was already provided at the rugby tournament were included in the present study, so this finding was not surprising. Also, the
average cost per follow-up injury in the present study (US$731) was about ten times less than moderate to serious injuries reported for rugby league between 1999 and 2007 (US$7100),18 although the rugby league study included players of all ages, not just youth. The finding that the injuries with the longest periods of recovery (more than 28 days = “severe”) were also the most expensive was expected and is consistent with findings in a population of high school sports participants in the United States.7 Severe injuries in the present study (US$1551) also cost much less than in the study of high school sports (US$35 336).7 The very different study designs could explain the discrepancies between the two studies. Nonetheless, the findings of the present study indicate an additional burden of injury that has not been identified in a youth rugby union cohort before, i.e. the economic burden of injury of player’s that seek follow-up treatment. For player’s seeking follow-up treatment this was, on average, US$731 and a median of 0.5 missed work days per injury for the parent/legal guardian. The higher average costs of upper extremity injuries in comparison to lower extremity injuries was unexpected and in contrast to what has been found in rugby league players of all ages,18 but was not dissimilar to general physical activity and sport injuries in children aged 10–12 years.8 The costs for both of these sites (upper and lower extremity) were greater in the present study than in that of rugby league players that involved all ages and both sexes. However, injury sites were not corrected for the possible confounding
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effect of injury type – therefore we cannot exclude the possibility that the significantly higher average cost of fractures (Table 2) could have influenced the mean cost of injury sites in the present study. The finding of higher average costs of fractures, in comparison to other injury sites in the present study was also in contrast with a rugby league report of all ages18 and study on knee injuries in Swiss youth sports.19 The average cost of fractures in the present study (US$2609) was also over 5 times greater than in the rugby league study (US$469).18 The relatively low average cost of head/neck injuries and, specifically, concussions in the present study (US$358) (Table 2) is surprising and in less than 70 times the cost in the rugby league study of all ages in New Zealand (US$25 347).18 Rugby league has comparable rates of concussion to rugby union and thus this difference could not be explained by injury rates between the two sports (Table 1).20 Of concern is that the low treatment costs associated with concussions in the present study could indicate that players did not consult a medical doctor or follow the correct return-to-play guidelines, which are considered “best-practice”21 and are strongly advocated by BokSmart/SARU for players with concussion.13 In fact, only 14% of all concussions (n = 7 of 50) received any form of follow-up treatment. Another explanation could be that the first-line medical professionals involved in assessing the concussed players both with medical aid, and especially those concussed players without medical aid, might also not be appropriately versed in the current scientific literature and medical protocols for correctly identifying, suspecting, diagnosing, treating and managing concussed players for safe return to play.22 This potential phenomenon of inadequate medical care could partially explain the finding that players with medical insurance had, on average, higher treatment costs than those players without medical aid: it is possible that those players without medical insurance did not receive optimal care for their injuries. In South Africa, access to medical insurance is linked to socioeconomic status and determines how one deals with a manageable disease such as hypertension.23 It is also possible that players with medical insurance could have received more treatment than was necessary for a particular injury. Thus, it is further possible that the absence or presence of medical insurance could have affected follow-up treatment-seeking behaviour. Although there were no significant differences in mean costs sustained in the different age groups (Table 2), this was expected due to the similar injury rates of the three age groups (Table 1). These findings support a study of high school sports participants in North Carolina, where age was also not considered a risk factor for the cost of injury albeit that age was categorised differently to that of the present study which based it’s categorisation on tournaments.7 Similarly, there was no significant difference in mean costs for players who did, or did not, mention having previously had the injury they were treated for – this phenomenon was also observed in the North Carolina High School study.7 However, comparable costs indicate that the costs for the present study might be greater than that of the North Carolina high school study in general. For example, the average medical cost of football-related injuries was $577 in the North Carolina high school study, while the comparable cost per injury for the present study was $731. A possible limitation of the present study was that only the 190 players who suffered what the tournament doctor predicted to be a “time-loss” injury were followed-up. This decision was made for logistical reasons as it would have been difficult to accurately follow-up all medical attention injuries telephonically. However, it is unlikely that many medical attention injuries required follow-up treatment. The cost estimations were based on numerous assumptions by the medical insurance company due to the unique situation in South Africa in which there is no prescribed standard rate for medical treatment costs. Thus, although the present method is
subject to potential inaccuracies as a result of these assumptions, the authors contend that any method of calculating costs in South Africa would require many assumptions. This approach of using an insurer to estimate costs also meant that the raw data were not available for conducting sensitivity analyses, which may limit the comparability of these findings to other countries although the unit cost and frequency of care (Supplementary material Table 1) should provide some allowance for comparison. Owing to the large discrepancy in average wage in South Africa, the authors were unable to estimate an indirect cost for the loss of the working time of the parents who had to take time off work to accompany their children to the health care practitioner. The classification of “old” or previous injury was also highly subjective, although it was difficult to implement a repeatable objective assessment in the circumstances in which these data were collected. Mean injury costs should have been corrected for different proportions of types of injuries (e.g. fractures, strains, etc.) in the different tournaments, but the study was statistically underpowered to be able to perform these analyses. Finally, comparisons between the present findings and other studies were limited due to a paucity of economic studies that investigated male youth athletes. 5. Conclusion Although the estimation of costs associated with the medical treatments described in the present study involved many assumptions due to the circumstances in which they were collected, this study is the first to quantify and compare monetary cost as an indication of injury burden in youth rugby union. In particular BokSmart, the national injury prevention programme in South Africa,13 should consider the high monetary costs of fractures and upper extremity injuries, in addition to injuries of large severity which have previously been identified.14 Furthermore, this study indicated the potential to significantly reduce the direct burden of injury to injured players, by dividing predicted injury costs amongst all players attending these tournaments, instead of just the relative minority who suffered an injury requiring follow-up treatment. This proposed model could potentially alleviate and offset individual injury costs at these types of tournaments, regardless of medical insurance status. Practical implications • This study describes the monetary cost of rugby union injuries of youth rugby players in South Africa seeking follow-up treatment for injuries sustained at national tournaments. • The costs are estimated from a health insurer’s perspective and thus are a conservative estimate of what these injuries could cost the parents/legal guardians of the injured players. • As the monetary costs of these injuries can be high, a description of injury severity/burden might be incomplete without this aspect of injury severity. • Players with long time-loss periods, and those suffering upper extremity injuries and fractures have high costs of injury. • Players suffering concussion and those without medical aid (insurance) may not be seeking adequate medical care before returning to play, which could predispose them to re-injury. Acknowledgments The authors would like to thank Ms Jill Borreson and Ms Kirsten Blair from Discovery Health for their assistance in calculating the medical costs related to these injuries and the treatments associated with the particular injuries.
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